Bariatric Surgery: The Benefits and Risks for Plan Sponsors

1 Second Quarter 2010. Bariatric surgery : The Benefits and Risks for plan Sponsors O. besity is a growing health problem in the United States. As the incidence of obesity has increased, so have the health problems associ- ated with it. These health problems place financial strain on the health-care system. When traditional methods Sarah Buckley Aon Consulting such as diet and exercise are unsuccessful, some obese individuals may turn to Bariatric (weight loss) surgery . Bariatric surgery is experiencing explosive growth fueled by this increasing obesity in the United States. Recent studies demonstrate that Bariatric surgery offers health Benefits to many morbidly obese individuals, Joseph Marlowe forcing increasing numbers of plan Sponsors to consider Aon Consulting covering it as part of the group medical plan .

2 However, plan Sponsors covering Bariatric surgery should consider limiting their coverage to include only proven centers of excellence, as explained in this article. obesity Challenge to Corporate America obesity is measured using Body Mass Index (BMI), a number calculated utilizing a person's height and weight. A. BMI of 25 to is considered overweight while a BMI of 30 to is considered obese (Centers for Disease Control 2009). Contents WorldatWork 2010. Reprinted from WorldatWork Journal, Second Quarter 2010, with permission from WorldatWork. Content is licensed for use by purchaser only. No part of this article may be reproduced, excerpted or redistributed in any form without express written permission from WorldatWork. To obtain permission, or to order electronic or print presentation-ready copies for distribution to colleagues, clients or customers, contact Gail Hallman, at Sheridan Press, 877-951-9191.

3 717-632-3535, ext. 8175. A BMI of 30 to is a weight of 203-270 pounds for a person of 5 feet 9 inches. A BMI over 40 is defined as morbidly obese (also known as class 3 obesity ). This is a weight of 271 pounds or more for a person of 5 feet 9 inches (HealthGrades 2009). Approximately 30 percent of adults are obese and the prevalence of obesity has increased rapidly in recent decades. Increasing numbers of children are overweight, which contributes to the high projections of obese adults in the future (National Business Group on Health 2009). If current patterns continue, projections indicate 43 percent of adults will be obese by 2018. (Thorpe 2009). obesity poses significant challenges to plan Sponsors . A recent study from a prominent obesity researcher found that 30 percent of medical cost increases during the past 15 years is due to obesity (Thorpe, et al.)

4 2007). The average obese individual costs $1,429 per year in additional medical expenses (Finkelstein 2009). This figure does not include the value of substantial lost worker productivity. Including lost worker productivity, obesity costs plan Sponsors $45 billion annually (National Business Group on Health 2009). obesity leads to 30 percent to 50 percent more chronic medical problems than heavy smoking or drinking (National Business Group on Health 2009). It contributes to coronary artery disease, cancer (breast, cervix, colon, esophagus, kidney, pancreas, prostate and uterus), diabetes, hypertension, pancreatitis, gall bladder problems, gout, infertility, liver problems and stroke. obesity alone causes 100,000 cancers each year in the United States (American Institute for Cancer Research Policy and Action for Cancer Prevention 2009).

5 It saps worker productivity. Finkelstein and Brown found that, on average, surgery -eligible obese employees missed more work days than normal-weight employees (2005). obesity cannot be ignored if plan Sponsors are to manage medical costs. Bariatric surgery The world of Bariatric surgery has changed remarkably over the past decade. In 2009, there were more than 250,000 Bariatric surgeries in the United States more than a 10-fold increase since 1998 (The Leapfrog Group 2009). Many plan spon- sors who decided not to cover Bariatric surgery have reversed course due to new evidence of better outcomes, health-status improvement and member demand. The risk of Bariatric surgery complications has significantly dropped, especially when performed by experienced surgeons in hospitals that do high volume.

6 The National Institutes of Health's guideline for Bariatric surgery requires a BMI of at least 40 or a BMI of at least 35, together with weight-related prob- lems such as diabetes and heart disease (2009). Many Bariatric surgeons and health plans follow the NIH guidance. Today, about 5 percent of Americans meet the NIH criteria of a BMI over 40 (National Business Group on Health 2008). It's intuitive that we plan toward the NIH criteria for Bariatric surgery being liberalized given the recent positive outcomes from Bariatric surgery Second Quarter | 2010 25. and new evidence that Bariatric surgery will aid diabetics with BMIs exceeding 30 who have difficulty controlling the condition. Types of Bariatric surgery Gastric bypass is the most common type of Bariatric surgery , with Roux-en-Y.

7 Being the most commonly performed gastric bypass surgery . Roux-en-Y gastric bypass (RYGBP) reduces stomach size, so patients feel full after eating small amounts of food. The RYGBP creates a small stomach pouch which bypasses part of the small intestine called the duodenum and attaches to the middle of the small intestine. Bypassing the duodenum causes fewer calories to be absorbed, but also greatly decreases the amount of iron and calcium absorbed so dietary supplements must be taken after surgery for the patient's lifetime, (The American Society for Metabolic and Bariatric surgery 2005, 2008). On average, patients shed 63 percent of their excess weight with gastric bypass surgery during the first 12 months (National Business Group on Health 2008). Surgeons can perform Roux-en-Y gastric bypass (RYGBP) on an open or laparoscopic basis.

8 Laparoscopy allows physicians to operate using small incisions causing less trauma to the patient during surgery and a shorter hospital stay. While laparo- scopic gastric bypass surgery has become more common than the open surgery , not all Bariatric surgery patients are candidates for laparoscopic surgery , thus surgeons still perform open gastric bypass surgeries (National Business Group on Health 2008). Laparoscopic adjustable gastric banding (LAGB) is the second most popular type of Bariatric surgery . In this surgery , a silicone band encircles the upper portion of the stomach reducing stomach size. Similar to gastric bypass, patients eat less because they feel full more quickly due to their reduced stomach size. The band is attached to a saline-filled balloon that can be adjusted to further reduce or increase the size of the stomach (The American Society of Metabolic and Bariatric surgery 2008).

9 The number of LAGB procedures has grown in recent years because it is less complex than RYGBP, enables quicker recovery and is easier to reverse. On average, patients lose 40 percent of their excess weight at 12 months with gastric banding (National Business Group on Health 2009). Two less common Bariatric surgeries are Vertical Sleeve Gastrectomy and Biliopancreatic Diversion with duodenal switch. Vertical Sleeve Gastrectomy removes a portion of the stomach thus reducing stomach size and decreasing the amount of food a patient can consume. In some patients, a bypass surgery follows the sleeve gastrectomy procedure to enhance weight loss (National Business Group on Health 2008). A study of vertical sleeve gastrectomy as an initial weight loss procedure found that patients who underwent vertical sleeve gastrectomy lost 46 percent of their excess weight at 12 months (Cottam 2006).

10 Biliopancreatic diversion with duodenal switch removes a portion of the stomach. This smaller stomach pouch bypasses the duodenum and is then connected to the 26 WorldatWork Journal small intestine. Reducing stomach size and bypassing the duodenum decreases the number of calories absorbed. On average, patients lose 63 percent to 75 percent of their excess weight within 12 months of surgery (National Business Group on Health 2008). Table 1 describes the advantages and disadvantages of these four Bariatric surgery procedures: The Economic and Health Benefits of Bariatric surgery On average, medical costs for the morbidly obese population are 81 percent higher than the non-obese population. plan Sponsors and health plans must weigh the economic and health Benefits of Bariatric surgery when making the decision to provide coverage.